Tag: Reimbursement

E&M Coding Advice: Simplified

E&M Coding Advice
Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedu

Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.

 

Carenodes medical executives offer the following highly simplified but useful “bottom-line” E&M coding advice. 

 

Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded.

 

  • Do not consider reporting the highest two codes of any code family:

  • When fewer than three distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter. 

  • Do not consider reporting the highest codes of any code family:

  • When fewer than four distinct medical conditions/complaints  were evaluated and managed during the encounter,
    OR
  • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter. 
  •  

 

This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that – by their clinical nature – usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.

 

Don’t Lose Revenue With an Outdated Fee Schedule

If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.

If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.

Remember, insurers typically will pay you either their allowable or your fee – whichever is lower. By charging less than the allowable, you are not getting the maximum reimbursement you are entitled to receive. If you are receiving 100 percent of your billed charge from a managed care plan, this could indicate your fee is set too low.

Many commercial plans base their fees on Medicare reimbursement, making it easier for you to evaluate their reimbursement patterns. As Medicare publishes its new fee schedule each year, you have an opportunity to compare your own fees against the new rates. At the same time, you can make revenue projections for the coming year and assess the value of your managed care contracts to your practice.